Templates by document

Therapy assessment report format and sample

A therapy assessment report format for six therapies, with sample entries for each section and a free PDF download.

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Formats for

Assessment reports by therapy

Speech therapy · In healhabSpeech therapy assessment report template and sampleA speech therapy assessment report format that takes you from referral to recommendations, with a sample entry for each findings section.
Speech therapy · In healhabShort speech and fluency assessment report templateA short speech and fluency assessment report format for one concern, such as stuttering, with sample entries throughout.
Occupational therapy · In healhabOccupational therapy assessment format with sample entriesAn occupational therapy assessment format from referral to recommendations, with a sample entry for each section and a free PDF download.
Occupational therapy · In healhabPaediatric OT sensory-motor assessment template and sampleA paediatric OT sensory-motor assessment format that links each finding to home and school routines, with sample entries and no test items.
ABA & behaviour therapy · In healhabABA and behaviour therapy assessment report format and sampleAn ABA and behaviour therapy assessment report format with sample entries, from referral and strengths to next steps.
ABA & behaviour therapy · In healhabFunctional behaviour assessment (FBA) template and exampleAn FBA template with sample entries that takes you from behaviour definitions and ABC data to reviewed hypotheses.
Early intervention & child developmentDevelopmental assessment report template and formatOne developmental assessment report for the whole team: a child development assessment format with fictional sample entries.
PhysiotherapyPhysiotherapy assessment format and form, with sample entriesA free physiotherapy assessment format that runs from history to treatment plan, with a sample entry under each section.
Multidisciplinary rehabilitationMultidisciplinary rehabilitation assessment template and sampleA rehabilitation assessment template that gathers each discipline's admission findings into one record, with sample entries for each section.

The essentials

What should a therapy assessment report include?

Details, referral, history, methods, findings, strengths, impression, recommendations and sign-off, in that order.

Identifying details: initials or name, date of birth, date of assessment, therapist and referral source.
Reason for referral and main concerns, in the family's own words where you can.
Relevant history: birth and medical history, previous therapy, education or work, and home languages.
Assessment methods: observation, interview, informal tasks and any published tests, with the result as the manual reports it.
Observations and findings by area, such as communication, motor skills, daily living or movement.
Strengths and interests, which shape how therapy will be delivered.

These sections appear in almost every assessment report. Each therapy template adds the domains of its discipline.

How do assessment reports differ across therapies?

The frame is shared. The findings section changes with the discipline.

Speech therapy: receptive and expressive language, speech sounds, fluency, voice, social communication and, where relevant, feeding.
Occupational therapy: motor skills, sensory processing, self-care, play, handwriting and participation. Often called an OT evaluation in the US.
ABA and behaviour therapy: skills across communication, social, daily living and learning readiness, and behaviours of concern with what comes before and after.
Early intervention: a whole-child picture across communication, movement, play, self-help and social-emotional areas, around family routines.
Physiotherapy: history, pain, posture, range of movement, strength, balance, gait and functional tasks, with precautions.
Rehabilitation: findings from each discipline, prior level of function and shared priorities.

The frame is shared, but the middle of the report changes with the discipline.

How do you record published tests in a report?

Name the test and edition, give the date and the result exactly as its manual reports it.

Name the test and edition, the date given, and the result in exactly the form its manual reports it. Note anything that affected testing, such as illness, a second language or a parent interpreting. Do not copy test items into the report; the record form stays in the file.

If you assessed informally, describe what you did. "Language was observed during free play and in conversation with the mother" tells the next reader far more than "informal assessment done".

Who is the report written for?

Professionals and families. Give a plain-language summary and keep conclusions in the impression section.

Professionals want methods and findings in enough detail to compare later. Families want to know what you saw and what happens now. A short plain-language summary, with technical terms explained once, serves both.

Write findings as observations: what the person did, where, with how much help. Keep conclusions in the impression section, where they read as the clinician's judgement.

What do Indian clinics usually add?

Every home language, who attends and cares daily, and the school's name, class and medium.

Record every language the person hears and uses, and which one you assessed in. Note who came with the person and who handles daily care. For school-age children, add the school, class and medium of instruction. Families share the PDF on phones, so keep the first page short and readable.

About assessment reports

A therapy assessment report records why a person was seen, what was assessed and how, what the therapist observed and found, and what is recommended next. Most formats run from identifying details and history through methods, observations and findings to impression, recommendations and sign-off. The templates below follow that order for each therapy.

The assessment report is usually the longest document you write for a person and the most widely read. Families keep it, schools ask for it, and doctors and other therapists use it to decide what happens next.

In India it is also called an assessment format, evaluation report or, in physiotherapy, a case sheet. Choose your therapy below to fill one in online.

Questions

Is there a filled sample of an assessment report?

Each therapy template page shows a fictional sample entry for each section, using initials only. The impression and summary sections have guidance only, because that wording belongs to the assessing clinician.

Is an assessment report the same as an evaluation report?

Yes. Evaluation is the more common term in the US; assessment is used in India and the UK. The structure is the same.

Can I download the assessment format as a PDF?

Yes. Open any template, fill it in online and download a PDF. You can also download it blank to fill in by hand.

Do these templates include a diagnosis section?

They include an impression or clinical summary section for the assessing clinician to write. Templates do not suggest wording for it, because that conclusion depends on the person assessed.

How long should an assessment report be?

Long enough to record methods, findings and recommendations clearly. Many run two to six pages; a short summary page helps families who will not read the full document.

Can I use the templates for adults?

Yes. The physiotherapy and rehabilitation templates suit adults and children, and the speech and OT templates can be adapted by removing child-specific prompts.

Write every report inside your clinic system.

Keep these as your clinic's own templates, write from reviewed session notes, publish branded PDFs, and keep families updated.

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